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DEPARTMENT OF HEALTH SERVICE Division of Public Health F-42017 (Rev. 12/08)


STATE OF WISCONSIN s. 252.04, Wis. Stats. (608) 267-3733 FAX: (608) 266-0049 Page 1 of 5

The refugee health assessment must be done with a trained medical interpreter or a medical provider fluent in the refugee's language. The purpose of this form is to assess the initial health status of refugees entering Wisconsin. Completion of this form is voluntary.

Perform the following lab tests as appropriate as part of the initial refugee health assessment:
Varicella screening if no verification of natural immunity Hepatitis B screening (anti-HBs, HBsAg, anti-HBc and IgM anti-HBc) Intestinal parasite screening, provide containers and instruct client with interpreter on collecting and returning specimens to the appropriate provider (e.g. clinic, local health department) Syphilis, Gonorrhea, Chlamydia and HIV testing CBC with differential Hemoglobin/hematocrit Urinalysis/pregnancy test Malaria screening if history or symptoms are suspicious of malaria Lead (children ages 6 months to 16 years of age within 90 days of arrival in the US.; children ages 6 months to 6 years (and older children if warranted) 3 to 6 months after placement into a permanent residence, regardless of initial test results). Tuberculosis (TB) testing UA/UC (Urinalysis/Urine culture) Other labs as appropriate for follow-up

Prior to initiating the health screening, verify the patient's admission status. Admission status refers to the classification that allows the patient to legally remain in the United States. To identify a patient's status: Request they present their Arrival/Departure Record (form I - 94) or a letter from the Office of Refugee Resettlement or from an immigration judge that documents the patient's status. Review the item and identify whether the patient's status is that of a Refugee, Asylee, Cuban/Haitian Entrant, Victim of Trafficking, or an Amerasian. Complete all information; Name, Date of Birth, Gender, Voluntary Agency (VOLAG)*, Alien Number, Country of Origin, Race, U.S. Arrival Date, Date of first clinic visit, Class B Status**, and reimbursement information in space provided at the top of page 3. *VOLAG refers to refugee resettlement voluntary agency. **Class B status refers to a condition (mental or physical) that was identified on the overseas medical examination prior to immigration to the United States. This condition represents a departure from normal health or well-being that is significant enough to possibly interfere with the person's ability to care for himself or herself, or to attend school or work, or that may require extensive medical treatment or institutionalization in the future. Assess immunizations: Review overseas medical exam (DS 2053) if available, and document immunization dates. According to the Advisory Committee on Immunization Practices (ACIP): Refugees <19 - update series, or begin primary series if no immunization dates are documented. Refugees 19 - assess for vaccines that are medically appropriate. For measles, mumps, and rubella indicate if there is laboratory evidence of immunity; if so, immunizations are not needed against those particular diseases. MMR vaccine can satisfy the immunization requirements for Measles, Mumps and Rubella. For varicella, if there is laboratory evidence of immunity or reliable history of the disease (e.g. dermatological manifestations), immunization is not needed. Document immunization information on the Refugee Health Assessment. Always update the personal immunization record card and instruct the patient and/or family, using an interpreter when needed. Call the Wisconsin Immunization Program at (608) 267-9959 for free immunization consultation if needed. NOTE: 07/2008 United States Citizenship and Immigration Service (USCIS) increased the vaccinations required for refugees seeking adjustment of status: Tuberculosis Screening: Apply Mantoux skin test to all patients regardless of BCG history, unless a rare medical contraindication is present. (Pregnancy is not a medical contraindication for Mantoux testing.) Apply Mantoux skin test to all patients 6 months or under if the child has HIV infection or if the child was exposed to an individual with active TB disease. (Make an immediate public health referral on a child with these circumstances.) The TB blood assay test (BAT) such as Quantiferon Gold TM or T-Spot TM may be used in place of the Mantoux for all persons over the age of 17. No published data document the performance of QFT-G in children aged <17 years [CDC/MMWR 12/16/05/54 (RR15); 49-55]. Schedule a child under 6 months of age, who is not HIV+ or a close contact, for a repeat Mantoux skin test after their 6-month birthday.

F-42017 (Rev. 12/08)

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Tuberculosis Screening Continued: Read Mantoux test in 48-72 hours and record results in millimeters of induration and/or record results of Blood Assay Test (BAT) on page three of this form. For all positive tests, record skin test /BAT and chest x-ray information on the Wisconsin TB Record form number DPH 4756 and provide to patient/family to facilitate initiation of treatment for latent TB infection or disease. Indicate if the refugee has any medical risk factors, which increase the risk for breaking down with active TB disease such as immunosuppression, low body weight, diabetes, etc. Chest x-ray MUST be done if: a. b. c. d. Mantoux is positive (for the person's risk factors) or blood assay test is positive Patient has been identified on their overseas medical exam (DS 2053) as having a class A or B TB condition Patient is symptomatic (cough, fever, hemoptysis, night sweats, weight loss, etc.) Patient is a recent contact, overseas or stateside, to active TB disease (Make an immediate public health referral.)

Indicate on the assessment form if medications for TB disease or TB infection were prescribed. All suspect or confirmed cases of TB should be reported immediately by telephone to the local health department. Oral Health: Complete in accordance with DPH oral health training. Check screening "not done" if you have not been trained. Ensure that oral health screening is initiated if you are unable to do it. Hepatitis B Administer Hepatitis B screening panel including Hepatitis B surface antigen (HBsAg), Hepatitis B surface antibody (anti-HBs), anti-HBc and IgM anti-HBc. Screen all household contacts of carriers and immunize susceptibles. Refer those who are HBsAg positive for additional medical evaluation. Consider HIV and STD screening for all persons who have reached sexual maturity or have a risk factor for HIV or an STD (family exposure, sexual abuse, etc.) HIV testing requires a separate written consent, according to Wis Statute 252.15(2). Screen for syphilis by administering VDRL or RPR. Confirm positive VDRL or RPR by FTA-ABS/TPPA or other confirmatory test. Repeat VDRL/FTA in 2 weeks if lesions typical of primary syphilis are noted and person is seronegative on initial screening. Screen for Chlamydia and gonorrhea using appropriate tests (even if asymptomatic). Screen for other STDs if symptomatic, if patient reports possible exposure, or you suspect exposure related to abuse. Intestinal Parasites: Evaluate for eosinophilia by obtaining a CBC with differential. Conduct stool examinations for ova and parasites. Three stool specimens should be obtained at least 24 hours apart. If parasites are identified, one stool specimen should be submitted 2-3 weeks after completion of therapy to determine response to treatment. Eosinophilia requires further evaluation for pathogenic parasites, even with 3 negative screening stool examinations. NOTE: The Wisconsin Division of Public Health does not recommend the use of rapid tests for identification of these parasites. Blood work: Document results. Pregnancy: Test if indicated and provide appropriate care or referrals. Malaria: If symptomatic, obtain three thick and three thin smears to screen for malarial parasites. Lead: Include lead testing when ordering lab work for children between ages 6 months to 16 years of age within 90 days of arrival in the US and for children ages 6 months to 6 years (and older children if warranted) 3-6 months after placement into a permanent residence, regardless of initial test results). or Assess for other health problems: Hematological disorders (eosinophilia, anemia, microcytosis), dental caries, nutritional deficiencies, thyroid disease, otorhinologic and ophthalmologic problems, history of trauma, dermatological abnormalities. Height, weight, vision and hearing evaluation and blood pressure. Assess mental health needs (e.g., headaches, nightmares, and depression). Screen for suicide potential if indicated and provide appropriate referrals. Communicable Disease Reporting: Wisconsin statute Chapter 252.05 and administrative Rule Chapter HFS 145 require reporting of suspect and confirmed communicable diseases. - Refer to Acute and Communicable Disease Case Report F-44151. Indicate on all referrals made for patient and if an interpreter is needed. Fill in all lab results in appropriate places throughout the form. Write name, address, phone/fax number and contact person of the agencies that provide the health screening on page 3. Include the Physician/PA/NP name and date completed. Fax all completed forms to (608) 266-0049 or mail to: Refugee Health Coordinator, PO Box 2659, Madison WI 53701-2659. For questions or further information on refugee health screening call the Wisconsin Refugee Health Coordinator at: (608) 267-3733.

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-42017 (Rev. 12/08) Page 3 of 5

STATE OF WISCONSIN s. 252.04, Wis. Stats. (608) 267-3733 FAX: (608) 266-0049
Client information is confidential under Wisconsin Statute 146.82 (1) Read instructions before completing this form.

Admission Status: Name (last, first, middle): Gender: Date of Birth (month, day, year): File/Case No: Resettlement Agency/VOLAG: Country of Origin: Race: Refugee Asylee Cuban/Haitian Victim of Trafficking Amerasian

Alien or Visa Registration No.: U.S. Arrival Date (month, day, year): Class B Status:

Date of First Clinic Visit for Screening (month, day, year): Interpreter Needed? Yes No If yes which language? Yes Literate in own language?

How will clinic be reimbursed for this Medical Assistance screening? Health Screening Contract Other


Vaccine- Preventable Disease/Immunization

Check if there is evidence of immunity; no immunization needed

Immunization Date(s) Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr

Measles Mumps Rubella Varicella (VZV) Diphtheria, Tetanus, and Pertussis (DTaP, DTP, DT) Diphtheria Tetanus (Td) / Tdap* Polio (IPV, OPV) Hepatitis B (Hep B) Haemophilus influenzae type b (Hib) Hepatitis A (Hep A) Influenza Pneumococcal Human Papillomavirus (HPV) Meningococcal conjugate (MCV) Rotavirus Zoster (shingles) *Tetanus, diphtheria and acellular pertussis (Tdap) vaccine can satisfy the Td booster requirement. Tdap vaccine is licensed for individuals 10 through 64 years of age.

Tuberculosis Screening:
Mantoux Skin Test Reaction (check one) Given regardless of history of BCG. Results: Date Placed: Date Read: mm induration Not done Blood Assay Test (BAT) Date: Result: Positive Negative Indeterminate Risk factors for TB disease: Medical risk factor (diabetes, immunosuppression, substance abuse, low body weight, etc.) Explain: TB Therapy: (if indicated) (check one) Treatment for suspected or confirmed active TB prescribed Date started: Treatment for latent TB infection (LTBI) prescribed; Date started: No LTBI treatment; Reason: Documented treatment overseas for active TB disease completed Pregnancy, HIV neg., no recent contact to active TB case Refused Other:

Chest x-ray: (taken in U.S.) (check one) Normal Non-TB Abnormality TB- non-cavitary TB- cavitary Stable, old TB Pending Not done, explain:

F-42017 (Rev. 12/08) Oral Health: (check all that apply)
Screening not done Untreated caries Early Childhood Caries Caries experience No natural teeth Sealants present Comments: Periodontal disease risk factors Signs of inflammation present Signs of inflammation present Treatment urgency: Early Urgent

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No obvious problem Prevention

Hepatitis B Screening
Anti-HBs (check only one) Negative Positive; Note: if positive, patient is immune Results pending Negative Positive Results pending HbsAg (check only one) Note: If positive, patient is infected with HBV and infectious to contacts, and it is especially important to screen all household contacts. If positive HbsAg, were all household contacts screened? Yes No If Yes, were all susceptibles started on vaccine? Yes No If No, why not? Referred for follow-up? Anti-HBc (check only one) Yes No Negative Positive Positive Yes No Results pending Results pending Not done Not done

IgM anti-HBc (check only one) Negative Note: If positive, patient has acute HBV infection.

If positive IgM anti HBC was patient referred for follow-up?

Sexually Transmitted Diseases: (check one for each of the following)
HIV* Syphilis Screening tests (VDRL/RPR) Confirmation test (FTA/TPPA) Gonorrhea Chlamydia Other, specify: Negative Negative Negative Negative Negative Negative Positive; referred to specialist? Positive; treated? Positive; treated? Positive; treated? Positive; treated? Positive; treated? Yes Yes Yes Yes Yes Tx: Tx: No No No Results pending Results pending Results pending Yes No Testing Not done, why? Not done, why? Not done, why? Not done, why? Not done, why? Not done, why?

*If HIV testing is done, a separate signed consent form for HIV testing must be completed.

Intestinal Parasite Screening:
Was screening for parasites done? Screened, results pending (Check all that apply) Treated? Ascaris Yes No Treated? Clonorchis Yes No Cryptosporidium Cyclospora
Entomaeba histolytica

Screened, no parasites found Hookworm Schistosoma Strongyloides Trichinella Trichuris Other Specify: Not screened for parasites; why?

Screened, parasite(s) found: Treated? Treated? Treated? Treated? Treated? Treated? Yes Yes Yes Yes Yes Yes No No No No No No

Treated? Treated? Treated? Treated?

Yes Yes Yes Yes

No No No No

Giardia Parasites not treated, why:

Blood Work
CBC with differential done? Was Eosinophilia present? If yes, was further evaluation done? Yes Yes Yes No No No No Results pending Hemoglobin Hematocrit ALT: Other: N/A AST: Results: Results: Not done Not done

Lead screening: (check only one)

Yes Results:

F-42017 (Rev. 12/08) Currently pregnant: (check only one) Malaria Screening: (check only one)
Not screened for malaria (not symptomatic) Ovale Falciparum Vivax Yes No Screened, results pending Malariae Yes; expected date of delivery No Not tested

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Screened, no malaria species in blood smears found Not identified Yes No

If malaria species found: Treated?

Referred for malaria treatment?

If referred for malaria treatment, specify physician/clinic: Significant information from patient history:

Significant information from physical exam:

Communicable Disease Reporting: Wisconsin statute Chapter 252.05 and administrative Rule Chapter HFS 145 require reporting of suspect and confirmed communicable diseases. Refer to Acute and Communicable Disease Reporting - DPH 4151 Referrals: (check all that apply) Primary Care Provider Vision Dermatology Communicable Disease, ID referral for: Communicable Disease, LHD referral for: Dental Hearing Public Health/WIC Family Planning Medical/Other: Mental Health referral for (check as appropriate): Post traumatic stress disorder (PTSD) Depression Anxiety Adjustment issues Domestic issues Substance Abuse Learning problems Other

Screening provider:
Agency One: Address: Telephone: ( Fax: ( Submitter: ) )

If more than one agency is involved in health assessment include information on both agencies.
Agency Two: Address: Telephone: ( Fax: ( ) )

Contact Number:

Fax completed form to the Wisconsin Department of Health Services, Division of Public Health, Bureau of Communicable Diseases, Refugee Health Coordinator at (608) 266-0049 or mail to:

Division of Public Health Attn: Refugee Health Coordinator PO Box 2659 Madison WI 53701-2659
Statement of Rights

Information on this form is collected for the Wisconsin Division of Public Health (DPH), by authority of Section 412(7) of the Immigration and Nationality Act as amended by the Refugee Act of 1980. This information is used to obtain a health evaluation and/or treatment for the patient. Wisconsin State Statute authorizes collection of this information under s. 250.04. In order to provide services, it may be necessary to release information from the patient's record to individuals or agencies that are involved in the care of the individual. Such individuals and agencies usually include family physicians and/or dentists, medical and dental specialists, public health agencies, hospitals, schools and day care centers. All public health agencies, health institutions, or providers to whom the refugee has appeared for treatment or services shall be entitled to the information included on this form.